Provider Demographics
NPI:1093972408
Name:WELLCARE OF GEORGIA, INC.
Entity Type:Organization
Organization Name:WELLCARE OF GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-206-1490
Mailing Address - Street 1:8735 HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1143
Mailing Address - Country:US
Mailing Address - Phone:813-290-6200
Mailing Address - Fax:
Practice Address - Street 1:211 PERIMETER CENTER PKWY NE
Practice Address - Street 2:STE 800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-1308
Practice Address - Country:US
Practice Address - Phone:866-300-1141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLCARE HEALTH PLANS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-22
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2005112302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA702909696AMedicaid